KEY POINTS
- The multidisciplinary ASTRO task force addressed four key questions covering indications and sequencing, dose and target volumes, treatment technique, and recurrent/metastatic/palliative disease. The systematic review ultimately incorporated 166 studies, with the literature search updated through June 16, 2026.
- For borderline resectable pancreatic cancer, preoperative chemoradiation or RT is now strongly recommended with moderate-quality evidence. For locally advanced disease, chemoradiation or RT after multiagent chemotherapy is also strongly recommended; patients should be reassessed for metastatic progression before proceeding to local therapy.
- Dose recommendations have become substantially more explicit. Preoperative resectable disease may receive 36 Gy in 15 fractions, while postoperative treatment should generally use 50–50.4 Gy in 25–28 fractions. For borderline resectable disease, standard options include 50–54 Gy in 25–30 fractions or 36 Gy in 15 fractions, while 33–40 Gy in 5 fractions is conditionally recommended as SBRT.
- ASTRO now provides a clear framework for dose escalation in locally advanced disease. Recommended options include 67.5 Gy in 15 fractions, 75 Gy in 25 fractions, or dose-escalated SBRT at >40–50 Gy in 5 fractions. These recommendations are strong but supported by low-quality evidence, so appropriate patient selection remains critical.
- Elective coverage is explicitly recommended for high-risk microscopic disease regions, including peritumoral margins, extrapancreatic neural tracts and regional nodal basins. Depending on fractionation, elective volumes may receive 45–50.4 Gy in 25–28 fractions, 36–37.5 Gy in 15 fractions, or 25–33 Gy in 5 fractions.
- Modern delivery is no longer treated as optional detail. IMRT/VMAT is recommended over 3D conformal RT, 4D CT should be used to assess respiratory motion, daily image guidance is recommended, and motion management is required for SBRT and dose-escalated moderately hypofractionated treatment. Most notably, adaptive RT is strongly recommended for dose-escalated SBRT to preserve target coverage while respecting gastrointestinal organ-at-risk constraints.
- The guideline also broadens the role of RT beyond newly diagnosed nonmetastatic disease. Definitive RT is recommended for isolated locoregional recurrence without prior RT; reirradiation is conditionally recommended, preferably after an interval of 6–12 months; and definitive local therapy is conditionally recommended for selected oligometastatic and oligoprogressive disease. For palliation of bleeding or pain, common schedules include 30 Gy in 10 fractions and 20 Gy in 5 fractions, while 25 Gy in one fraction to the celiac plexus may be considered for selected pain syndromes.
CLINICAL TAKEAWAY
The 2026 ASTRO guideline moves pancreatic RT beyond a simple chemoradiation-versus-no-radiation question and provides a practical framework for dose escalation, elective coverage, adaptive treatment, reirradiation and metastasis-directed therapy. It is highly relevant to practice, but several of its most aggressive recommendations—particularly dose escalation and oligometastatic treatment—still rest on low-quality evidence and require experienced multidisciplinary selection.